Form 4 Motion And Affidavit For Permission To Proceed In Forma Pauperis {4}

UNITED STATES COURT OF APPEALS FOR THE NINTH CIRCUITForm 4. Motion and Affidavit for Permission to Proceed in Forma PauperisInstructions for this form: http://www.ca9.uscourts.gov/forms/form04instructions.pdf 9th Cir. Case Number(s) Case NameAffidavit in support of motion: I swear under penalty of perjury that I am financially unable to pay the docket and filing fees for my appeal. I believe my appeal has merit. I swear under penalty of perjury under United States laws that my answers on this form are true and correct. 28 U.S.C. 247 1746; 18 U.S.C. 247 1621. Signature Date The court may grant a motion to proceed in forma pauperis if you show that you cannot pay the filing fees and you have a non-frivolous legal issue on appeal. Please state your issues on appeal. (attach additional pages if necessary)Feedback or questions about this form? Email us at forms@ca9.uscourts.gov Form 41Rev. 12/01/2018 American LegalNet, Inc. www.FormsWorkFlow.com 1. For both you and your spouse, estimate the average amount of money received from each of the following sources during the past 12 months. Adjust any amount that was received weekly, biweekly, quarterly, semiannually, or annually to show the monthly rate. Use gross amounts, that is, amounts before any deductions for taxes or otherwise. Average monthly amount during the past 12 months Amount expected next month Income Source You Spouse You Spouse Employment $ $ $ $ Self-Employment $ $ $ $ Income from real property (such as rental income) $ $ $ $ Interest and Dividends $ $ $ $ Gifts $ $ $ $ Alimony $ $ $ $ Child Support $ $ $ $ Retirement (such as social security, pensions, annuities, insurance) $ $ $ $ Disability (such as social security, insurance payments) $ $ $ $ Unemployment Payments $ $ $ $ Public-Assistance (such as welfare) $ $ $ $ Other (specify) $ $ $ $ TOTAL MONTHLY INCOME: $ $ $ $Feedback or questions about this form? Email us at forms@ca9.uscourts.gov Form 42Rev. 12/01/2018 American LegalNet, Inc. www.FormsWorkFlow.com 2. List your employment history for the past two years, most recent employer first. (Gross monthly pay is before taxes or other deductions.) Employer Address Dates of Employment Gross Monthly Pay From To $ From To $ From To $ From To $3. List your spouse's employment history for the past two years, most recent employer first. (Gross monthly pay is before taxes or other deductions.) Employer Address Dates of Employment Gross Monthly Pay From To $ From To $ From To $ From To $Feedback or questions about this form? Email us at forms@ca9.uscourts.gov Form 43Rev. 12/01/2018 American LegalNet, Inc. www.FormsWorkFlow.com 4. How much cash do you and your spouse have? $Below, state any money you or your spouse have in bank accounts or in any other financial institution. Financial Institution Type of Account Amount You Have Amount Your Spouse Has $ $ $ $ $ $ $ $If you are a prisoner seeking to appeal a judgment in a civil action or proceeding, you must attach a statement certified by the appropriate institutional officer showing all receipts, expenditures, and balances during the last six months in your institutional accounts. If you have multiple accounts, perhaps because you have been in multiple institutions, attach one certified statement of each account.5. List the assets, and their values, which you own or your spouse owns. Do not list clothing and ordinary household furnishing. Home Value Other Real Estate Value $ $ Motor Vehicle 1: Make & Year Model Registration # Value $ Motor Vehicle 2: Make & Year Model Registration # Value $Feedback or questions about this form? Email us at forms@ca9.uscourts.gov Form 44Rev. 12/01/2018 American LegalNet, Inc. www.FormsWorkFlow.com Other Assets Value $ $ $6. State every person, business, or organization owing you or your spouse money, and the amount owed. Person owing you or your spouse Amount owed to you Amount owed to your spouse $ $ $ $ $ $7. State the persons who rely on you or your spouse for support. If a dependent is a minor, list only the initials and not the full name. Name Relationship Age Feedback or questions about this form? Email us at forms@ca9.uscourts.gov Form 45Rev. 12/01/2018 American LegalNet, Inc. www.FormsWorkFlow.com 8. Estimate the average monthly expenses of you and your family. Show separately the amounts paid by your spouse. Adjust any payments that are made weekly, biweekly, quarterly, semiannually, or annually to show the monthly rate. You Spouse Rent or home-mortgage payment (include lot rented for mobile home) $ $- Are real estate taxes included? Yes No - Is property insurance included? Yes No Utilities (electricity, heating fuel, water, sewer, and telephone) $ $ Home maintenance (repairs and upkeep) $ $ Food $ $Clothing $ $ Laundry and dry-cleaning $ $ Medical and dental expenses $ $ Transportation (not including motor vehicle payments) $ $ Recreation, entertainment, newspapers, magazines, etc. $ $ Insurance (not deducted from wages or included in mortgage payments) - Homeowner's or renter's $ $ - Life $ $ - Health $ $ - Motor Vehicle $ $ - Other $ $ Taxes (not deducted from wages or included in mortgage payments) Specify $ $Feedback or questions about this form? Email us at forms@ca9.uscourts.gov Form 46Rev. 12/01/2018 American LegalNet, Inc. www.FormsWorkFlow.com You Spouse Installment payments - Motor Vehicle $ $ - Credit Card (name) $ $ - Department Store (name) $ $Alimony, maintenance, and support paid to others $ $ Regular expenses for the operation of business, profession, or farm (attach detailed statement) $ $ Other (specify) $ $ TOTAL MONTHLY EXPENSES $ $9. Do you expect any major changes to your monthly income or expenses or in your assets or liabilities during the next 12 months? Yes NoIf Yes, describe on an attached sheet.10. Have you spent227or will you be spending227any money for expenses or attorney fees in connection with this lawsuit? Yes No If Yes, how much? $ 11. Provide any other information that will help explain why you cannot pay the docket fees for your appeal.12. State the city and state of your legal residence. City State Your daytime phone number (ex., 415-355-8000) Your age Your years of schoolingFeedback or questions about this form? Email us at forms@ca9.uscourts.gov Form 47Rev. 12/01/2018 American LegalNet, Inc. www.FormsWorkFlow.com